Training the Prescriber: An Institutional Effort to Reduce the Amount of Opioids Prescribed Following Lumbar Surgery
As we all know, opioid addiction in the US has reached epidemic proportions. In 2017 alone, opioids were involved in the overdose deaths of 47,600 people. Many victims of opioid abuse began their journey with physician-prescribed medications that initially were provided for the management of acute or chronic pain. Often the source of this pain is damage to the lumbar spine or a temporary side effect of lumbar spine surgery.
Physicians and medical institutions are actively seeking solutions to lower the risks of opiate addiction. One focus is reducing the amounts of opioids that are initially prescribed for patients in acute pain. Excess opioid medication has the potential to lead to addiction in patients or misuse by family members or others with access to leftover opioid pills.
At Hospital for Special Surgery (HSS) in New York City (ranked Number 1 in orthopedics 2018–19 by U.S. News & World Report), a task force developed a 1-hour educational program on opiate use and misuse, the role of the orthopedic prescriber, multimodal analgesia, and state laws regarding opioid prescription. All opioid prescribers at the institution were mandated to attend the program in person or via an online presentation. A committee composed of spine surgeons, pain management physicians, anesthesiologists, and nurse managers established guidelines for prescribing opioids following spine surgery. These qualitative guidelines, based on individual patients’ consumption of opioids while in the hospital, were disseminated throughout the hospital early in 2017.
In the article "An institutional intervention to modify opioid prescribing practices after lumbar spine surgery," published today in the Journal of Neurosurgery: Spine (https://thejns.org/spine/view/journals/j-neurosurg-spine/aop/article-10.3171-2018.8.SPINE18386.xml), Francis Lovecchio, MD, and colleagues address the question of whether this intervention—mandatory provider education together with prescription guidelines—could change prescriber behavior, resulting in a lower amount of opioids prescribed at hospital discharge after lumbar surgery.
Lovecchio and colleagues compared opioid prescription data in the electronic medical records of 1177 patients treated by lumbar surgery before the intervention (March 1–November 1, 2016) with similar data in the electronic medical records of 1302 patients treated after the intervention (February 1–October 1, 2017). Because a variety of opioid medications with different strengths had been prescribed, the researchers converted the amount of opioid per prescription into an oral morphine equivalent (OME) to make comparisons possible.
The researchers found a statistically significant reduction in both the mean amount of opioid (629 ± 294 OME pre-intervention vs. 490 ± 245 OME post-intervention, p < 0.001) and the mean number of opioid pills (81 ± 26 pre-intervention vs. 66 ± 22 post-intervention, p < 0.001) prescribed after the intervention. In fact, prescriptions for 81 or more pills decreased from 65.5% to 25.5%. The researchers also found that the rate of refill prescriptions requested by patients within 6 weeks after surgery increased after the intervention; however, the difference was not significant. The researchers take this to suggest that overall pain control was not significantly altered by the reduction in prescribed opioids.
The researchers estimate that in the 8 months following dissemination of the guidelines, "the change in prescribing practices may have saved the dispensing of over 26,000 narcotic pills."
Lovecchio and colleagues show how the intervention at HSS changed prescriber behavior, resulting in a lower amount of prescribed opioids. They suggest that future studies should be undertaken to focus on how these changes in prescriber behavior may affect patient outcomes.
When asked about the importance of the study, Dr. Lovecchio said, "While we have been able to show that qualitative prescribing guidelines work to change prescriber behavior, the most practical solution to overprescribing is to define the 'minimum necessary quantity' of opioid to prescribe for the average patient after a given spine procedure. This will prove challenging, as postoperative opioid consumption likely depends on a complex interplay of biological, psychosocial, and surgery-related factors, and patient expectations. Our group and many others are working toward this end, and I look forward to finding solutions."
Lovecchio F, Stepan JG, Premkumar A, Steinhause ME, Sava M, Derman P, Kim HJ, Albert T: An institutional intervention to modify opioid prescribing practices after lumbar surgery. J Neurosurg Spine, published ahead of print February 5, 2019. DOI: 10.3171/2018.8.SPINE18386.
About The Journal of Neurosurgery: Spine
The Journal of Neurosurgery: Spine is a monthly peer-reviewed journal focused on neurosurgical approaches to treatment of diseases and disorders of the spine. It contains a variety of articles, including descriptions of preclinical and clinical research as well as case reports and technical notes. The Journal of Neurosurgery: Spine is one of four monthly journals published by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons. Other peer-reviewed journals published by the JNS Publishing Group each month include the Journal of Neurosurgery, Neurosurgical Focus, and the Journal of Neurosurgery: Pediatrics. All four journals can be accessed at www.thejns.org.
About the American Association of Neurological Surgeons
Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 10,000 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system including the brain, spinal column, spinal cord, and peripheral nerves. For more information, visit www.AANS.org.
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year), No. 3 in rheumatology by U.S.News & World Report (2018-2019), and named a leader in pediatric orthopedics by U.S.News & World Report “Best Children’s Hospitals” list (2019-2020). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In addition, HSS will be opening a new facility in Florida in late 2019. In 2018, HSS provided care to 139,000 patients and performed more than 32,000 surgical procedures, and people from all 50 U.S. states and 80 countries traveled to receive care at HSS. There were more than 37,000 pediatric visits to the HSS Lerner Children’s Pavilion for treatment by a team of interdisciplinary experts. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is the world’s leading provider of education on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.